10-144-332 Me. Code R. § 3.5-2

Current through 2024-51, December 18, 2024

Section 144-332-3.5-2 - ELIGIBILITY GROUPS FOR WHICH MAGI-BASED METHODOLOGY APPLIES

To be eligible for MaineCare in the category of a Categorically Needy eligibility group for which MAGI-based methodology applies, an individual must:

A. be a covered individual;

B. have an eligibility group;

C. meet basic eligibility criteria in this Part and in Parts 2 and 17.5; and

D. meet income criteria.

In order to get Medicaid coverage under an eligibility group for which MAGI-based methodology applies, an individual must meet the criteria of at least one of the groups below. An individual may meet the criteria of more than one group at the same time in which case they should be enrolled with the group which is the easiest way for them to get the best coverage.

Section 2.1:Children

An individual who is under the age of 21.

A. Newborns

(1) If the newborn's mother is receiving Medicaid (or is covered as part of the retroactive period) on the date the baby is born, the baby is eligible regardless of the income of the household. The mother must be fully covered by Medicaid on the day of the baby's birth. In other words, if mother meets the deductible amount on the day of the baby's birth and is partially responsible for any medical bills on that date, the newborn is not eligible in this group.

(2) Coverage continues for one year. This means that the baby is eligible without regard to changes in income or composition of the household.

B. Other children under age 1

(1) Individuals under the age of one who are living with a parent/caretaker relative or with unrelated others are eligible if they meet other applicable eligibility rules in Parts 2 and 17.5.

(2) Countable income must be equal to or less than the applicable standard in Part 17.5.

(3) If the individual is receiving inpatient hospital services on the last day of the month in which the first birthday occurs, eligibility continues until the last day of the in-patient stay if the individual continues to meet all other eligibility criteria.

C. Age 1 through Age 18

(1) Individuals age 1 up to and including age 18 (under age 19) who are living with a parent/caretaker relative or who are living alone or with unrelated others are eligible for Medicaid if they meet other applicable eligibility rules in Part 2 and Part 17.5.

(2) Countable income must be equal to or less than the applicable income standard in Part 17.5.

(3) If the individual is receiving inpatient hospital services on the last day of the month in which the 19th birthday occurs, eligibility continues until the last day of the inpatient stay if the individual continues to meet all other eligibility criteria.

D. Age 19 or 20

(1) Individuals age 19 or 20 who are living with parent/caretaker relatives or who are living alone or with unrelated others are eligible for Medicaid if they meet other applicable eligibility rules in Part 2 and Part 17.5.

(2) Countable income must be equal to or less than the applicable income standard in Part 17.5.

(3) If the individual is receiving inpatient hospital services on the last day of the month in which the 21st birthday occurs, eligibility continues until the last day of the in-patient stay if the individual continues to meet all other eligibility criteria.

Section 2.2: Parent/Caretaker Relative

A parent/caretaker relative means a relative of a dependent child by blood, adoption or marriage with whom the child is living, who assumes primary responsibility for the child's care (as may, but is not required to, be indicated by claiming the child as a tax dependent for Federal income tax purposes), and who is one of the following:

A. The child's father, mother, grandfather, grandmother, brother, sister, `stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;

B. The spouse of such parent or relative, even after the marriage is terminated by death or divorce; or

C. Another relative of the child based on blood (including those of half-blood), adoption or marriage.

Countable income must be equal to or less than the applicable income standard in Part 17.5.

(1) Maintenance of a Home

A parent/caretaker relative is potentially eligible only if he/she is living with a dependent child for whom a home is maintained and that child is also covered by Medicaid. The child must be under age 18 or is age 18 and expects to graduate from high school prior to their 19th birthday.

The specified relative does not need to have legal custody as a result of court action in order to be considered to be maintaining a home for the child.

If the child lives part of the time with each parent, the parent with whom the child resides over 50% of the time must apply for the child.

If the child lives 50% of the time with each parent, either parent can apply for the child but not both.

If a child is living with his/her biological parents but the parents are not married, all three have a coverable group and are potentially eligible. Each parent has a coverable group because each is residing with their child under age 18 (or 18 and expects to graduate from high school by age 19).

If the only child is between the ages of 19 and 21, (or is age 18 and does not expect to graduate from high school prior to the 19th birthday), the parent or caretaker relative cannot receive Medicaid coverage unless the parent or caretaker relative is eligible in another category (e.g., a pregnant woman or meets SSI disability criteria).

Examples

(a) The household consists of a single mother and her 18 year old son. In June, the boy graduates from high school. The boy may remain eligible for Medicaid since he has a coverable group (under age 21).

The mother is no longer eligible. She has no coverable group since she is not living with a dependent child covered by Medicaid and she is not pregnant and does not meet SSI disability criteria.

(b) The household consists of a mother, father, and their 19 year old daughter. The daughter may be eligible, depending on the income requirements of her coverage group, however, the parents cannot be covered as a parent/caretaker relative.

(c) The household consists of a mother, father, and 17 year old girl who is a sophomore in high school. On the child's eighteenth birthday, the parents' coverage is due to end. Discussion with the family prior to terminating the parents' coverage reveals that the mother has a condition which might meet disability criteria under the SSI program. Coverage for the girl continues. Coverage for the father is terminated. Coverage for the mother continues pending a decision from the Medical Review Team on her disability. If she does not meet criteria for SSI - Related disability (see Part 6, Section 4.3), her coverage must also end.

(d) An individual, age 20, is the caretaker relative of his 18 year old sister. When the sister graduates from high school, both can continue to receive Medicaid as both are still eligible for coverage through the infants and children under age 21 group.

(2) Physical Separation

A child may be separated physically from his/her parent/caretaker relative and still be considered to be living with the parent/caretaker relative, provided that the parent/caretaker relative retains full and exclusive responsibility for the supervision and guidance of the child, offers a home during vacations, and any other delegation of authority to another by the parent/caretaker relative is temporary, voluntary, and revocable. When separation occurs, it is expected that the child or parent/caretaker relative will return home at the completion of the reason for the separation. The following criteria meet the conditions for when a child or parent/caretaker relative is away from the home.

(a) To secure education when high school facilities are not maintained in the place of residence or if existing facilities do not meet the child's educational or social needs. In this later instance, the assessment of needs and the development of a responsible plan must be made through the parent/caretaker relative and a recognized social service agency.

(b) To secure planned supervised therapy in a private, organized treatment center such as Sweetser Home, when such is necessitated by special needs of a physical or emotional nature.

(c) To attend Governor Baxter State School for the Deaf, provided that adequate resource for therapy can be found or developed in the child's own community.

(d) To attend a vocational or technical school or college or university.

(e) For care for a terminal illness which probably will prohibit eventual return to the home, although if possible the individual would do so.

(f) For other purposes, such as visiting or moving to another community and similar situations where temporary separation occurs. In such situations, the separation may not exceed four months, unless the individual can demonstrate that there is a good reason and that the separation will end as soon as possible.

Section 2.3: Pregnant Women

Pregnant woman means a woman during pregnancy and the post-partum period, which begins on the date the pregnancy ends, extends 60 days, and then ends on the last day of the month in which the 60-day period ends..

Pregnant women whose countable income is equal to or below the applicable income standard in Part 4.5 are eligible. The household size is increased by one (or by two if the woman is expecting twins). Cooperation with Third Party Liability (TPL) and Division of Support Enforcement and Recovery (DSER) is not a factor in determining eligibility.

Retroactive coverage may be granted for up to three months if the woman was pregnant and financially eligible.

If a woman is eligible as a pregnant woman in the month of application, or the retroactive period, or due to a change in ongoing eligibility, she continues to be eligible for sixty days beyond the date her pregnancy ends and through the last day of the month in which the 60th day falls.

Only the pregnant woman is eligible under coverage group. Other family members must be in another coverable group.

If the individual is receiving inpatient hospital services on the last day of the month in which coverage as a pregnant woman occurs, eligibility continues until the last day of the in-patient stay if the individual continues to meet all other eligibility criteria in Part 2 and Part 17.5.

A. Presumptive Eligibility for Pregnant Women

A pregnant woman is eligible to receive ambulatory prenatal care beginning on the day that a qualified Medicaid provider determines that the pregnant woman's household's countable MAGI-based income is less than the applicable income standard in Part 4.5. This coverage is called "presumptive eligibility".

The qualified Medicaid provider will use a presumptive eligibility application to establish the MAGI household size and income for the presumptive determination. The Medicaid provider must contact the regional office of Medicaid within five working days after the date the presumptive determination is made to report the name, date of birth, and Social Security number of each woman determined eligible under the presumptive eligibility standards.

Once the Medicaid provider has made a presumptive determination, the woman is eligible through the last day of the month following the month in which a presumptive determination is made. If the woman applies for Medicaid during this presumptive eligibility period, presumptive eligibility continues through the day that the Medicaid application is granted or denied.

Example

A pregnant woman is determined presumptively eligible by the Medicaid provider on September 14th. She receives coverage under presumptive eligibility through October 31st. On October 31st she files an application for Medicaid. Because she applied for Medicaid within the presumptive eligibility period, the individual continues to be presumptively eligible through the day the application is granted or denied.

The Eligibility Specialist is required to provide appropriate notices based on the Medicaid application itself, but is not required to send any notice regarding the discontinuance of the presumptive eligibility period and the individual has no rights of appeal.

It is the responsibility of the Medicaid provider to:

provide the applicant with an approved standard MaineCare application form; notify OFI of the presumptive eligibility determination within five working days from the date the determination was made; notify the applicant (in writing and orally if appropriate) that if the applicant does not file a standard MaineCare application with OFI before the last day of the following month, presumptive eligibility coverage will end on that last day; notify the applicant (in writing and orally if appropriate) that if the applicant files a standard MaineCare application with OFI before the last day of the following month, presumptive eligibility coverage will continue until an eligibility determination is made on the application that was filed.

10-144 C.M.R. ch. 332, § 3.5-2